Appendix D: Included Studies adverse effects review

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1 DELIRIUM APPENDICES (Draft for Consultation) Appendix D: Included Studies adverse effects review Table D1: Studies directly comparing two antipsychotic agents in delirium Author Study design Setting Age Male /Female Lee 2005 Randomized Treatment of controlled delirium in trial. No hospital blinding. Miyaji 2007 Skrobik 2004 Retrospective review of medical records. No blinding. Quasirandomized controlled trial. No blinding. Treatment of delirium in hospital Treatment of delirium in the critical care setting Drug & Dose Comparator Mean duration 61 20/20 Amisulpiride 156 mg daily (mean) Quetiapine 113mg daily (mean) Median /87 1. Oral haloperidol. Initial dose - median 0.75 (interquartile ) mg. Max dose - median 1.5 (interquartile ) mg. 2. Intravenous or intramuscular haloperidol. Initial dose - median 5 (interquartile 2.5-5) mg. Max dose - median 5 (interquartile ) mg /20 Olanzapine 5 mg (2.5mg for > 60 years) Risperidone Initial dose - median 0.5 (interquartil e 0.5-1) mg. Max dose - median 1 (interquartil e 0.5-2) mg. Haloperidol initiated at mg every 8 h, with lower dose 0.5-1mg for age >60 years. 7 days Median 11 days. Mainly for 1 day only Page 1 of 14

2 Table D1b: Studies directly comparing two antipsychotic agents in delirium (cohort studies) Author Study design Setting Age Male /Female Gill 2005 Cohort study Incidence of Mean 82.6 Atypical (retrospective ischaemic antipsyc and stroke in hotics prospective older adults 6424/11 elements). with 420 dementia antipsyc hotics 5797/90 Herrmann 2004 Cohort study (retrospective ). Incidence of stroke in older adults Mean antipsyc hotics 345/670 Risperid one 2159/48 05 Olanza pine 1061/23 60 Drug & Dose Risperidone (75.7%) Olanzapine (19.4%) Quetiapine (4.9%) High and low potency atypical antipsychotics prescribed Risperidone (61%) Olanzapine (30%) antipsychotics (9%) Mean duration Atypical days days 13,318 person years

3 DELIRIUM APPENDICES (Draft for Consultation) Table D2: Studies directly comparing two antipsychotic agents in delirium Author Lee 2005 Miyaji 2007 Methods used for AEs All adverse events were recorded but method not stated Two physicians checked case notes for any unfavourable sign, symptom or condition, or was listed as an adverse reaction in drug information leaflet, Events recorded irrespective of causality. Drug Comparator Drug AE details Comparator AE details Amisulpiride n=20 Oral haloperidol n=:95 IV/IM haloperidol: n=61 Quetiapine n=20 Risperidone : n=93 Oversedation - 1 Acute dystonia and dyskinesia were not observed Oversedation - 1 Acute dystonia and dyskinesia were not observed Haloperidol Oral IV/IM Control Excessive sedation 19 7 (11%) Excessive sedation 2 (2%) (20%) EPS EPS 2 (2%) (14%) (16%) Mortality during delirium 2 8 Mortality during delirium 3 (3.2%) (2.1%) (13.1%) Mortality within 1 yr after onset of delirium: 28 (29.5%) 28 (45.8%) Mortality within 1 yr after onset of delirium: 28 (30.1%) Hepatic function disorder Cerebral infarction Hypothermia 1 (1%) 1 (1%) 1 (1%) Convulsions 1 (1%) Skrobik 2004 Noted any use of antiparkinsonian medication for extrapyramidal side effects; Extrapyramidal signs were carefully recorded by physician using 2 scales Olanzapine n=45 Haloperidol n=28 Incidence of any AE 30 (31.4%) 20 (32.8%) Vital signs, and liver function tests were no different between groups. Patients on olanzapine had no extrapyramidal manifestations. Incidence of any AE: 6 (6.5%) For haloperidol, 6 patients noted to have low scores on extrapyramidal symptom testing (1 for the Ross Chouinard, 1-4 for the Simpson- Angus scale). No patient in either group received prophylactic or therapeutic antiparkinsonian therapy. Page 3 of 14

4 Gill 2005 Herrmann 2004 Patients were observed until they were admitted to hospital with ischaemic stroke, stopped taking their antipsychotic, died or the study ended Patients were observed until they were admitted to hospital for stroke, exposure to a medication from another study group, discontinuation of the drug, death or the end of the observation period Atypical n=17845 n=1015 n=14865 Risperidone n=6964 Olanzapine n=3421 Incidence of ischaemic stroke Incidence of stroke Incidence of ischaemic stroke Incidence of stroke

5 DELIRIUM APPENDICES (Draft for Consultation) Table D3: Study comparing all antipsychotics (typical and atypical) against control Author Study design Setting Age Male /Female Douglas 2008 Selfcontrolled not reporte case-series d Patients from the General Practice Research Database Median age to first exposure to any antipsychotic drug 80 Drug & Dose 1 Atypical antipsychotics: Risperidone (81%) Olanzapine (18%) Quetiapine (4%) Amisulpride (4%) antipsychotics: Phenothiazine (81%) Butyrophenone (20%) Thioxanthine (12%) Sulpride (3%) Mean duration Median duration of antipsychotic exposure 0.37 years (IQR 0.10 to 1.23) Author Methods used for AEs Drug Drug AE details Comparator AE details Douglas Atypical Incidence of stroke Incidence of stroke 2008 antipsychotics Intraperson comparisons in a population of individuals who have both the outcome (stoke) and exposure (antipsychotic) antipsychotics Page 5 of 14

6 Table D4: Studies comparing haloperidol against control in delirium Author Study design Setting Age Male Drug & Dose 1 Comparator Mean duration /Female Kalisvaart /172 Haloperidol 1.5mg daily Placebo 1-6 days (range) Kaneko 1999 Randomized, placebocontrolled, double-blind trial Randomized controlled trial. No blinding. Prevention of delirium in patients having hip surgery Prevention of delirium after GI surgery 72 24/14 Haloperidol 5 mg intravenous Saline 5 days Table D5: Studies comparing haloperidol against control in delirium Author Methods used for AEs Drug Comparator Drug AE details Comparator AE details Kalisvaart Haloperidol Placebo 218 Withdrawals due to AE: 3 Withdrawals due to AE: n=212 Kaneko 1999 Daily examination by the treating surgeons, spontaneous reports from the patients, and specific assessments; the Barnes Akathisia Scale and ECG, Daily BP, and assessment for sedation and extrapyramidal signs. Frequent reassessment of the patient s mental state and careful monitoring for side effects. Haloperidol n=40 Saline n=40 No drug-related side effects were seen during the study period. Values on the Barnes Akathisia Scale were 0 for all the patients in both groups. There was no sedation reported, Extrapyramidal side effects not noted with intervention; however, one patient who was administered haloperidol developed transient tachycardia. No other complication

7 DELIRIUM APPENDICES (Draft for Consultation) Table D6: Studies comparing atypical antipsychotics against control in delirium Author Study design Setting Age Male /Female Breitbart 2002 Open trial Treatment of mean 60.6, delirium in range hospitalized cancer patients Kim 2001 Open trial Treatment of delirium in hospital Pae 2004 Parellada 2004 Prakanratta 2007 Pilot trial, open label study Prospective multicentre observational in 5 hospitals Randomized, double blind, placebo controlled Treatment of delirium in hospital Treatment of delirium in hospital Prevention of delirium following cardiac surgery Mean 45.8 (SD 18.3), range (SD 9.8), range Drug & Dose Comparator Mean duration 40/39 Olanzapine. Mean starting dose 3 mg (range ). Dose after 2-3 days (T2) mean 4.6 mg (range ). Dose after 4-7 days (T3) mean 6.3mg (range ) 15/5 Olanzapine mean 5.9 (SD 1.5) mg/day. Initial mean 4.6 (SD 0.9) mg/day. Max mean 8.8 (SD2.2) mg/day 13/9 Quetiapine (flexible dose). Mean daily dose (SD 72.2) mg. Mean init. dose 37.5 (SD 12.8) mg/day. Mean max dose (SD 121) mg/day. None None None 4-7 days 67 40/24 Risperidone 2.6 mg (mean) None 7 days 6.6 (SD 1.7) days 8.5 (SD 4.5) days 61 74/52 Risperidone 1mg single dose Placebo Single dose Page 7 of 14

8 Table D7: Studies comparing atypical antipsychotics against control in delirium Author Breitbart 2002 Methods used for AEs Clinical (physical) examination Drug Comparator Drug AE details Comparator AE details Olanzapine n= 79 None Sedation 24 (30%) - reduced dosage for 8 pts. Rash, pruritus, nausea, stomach ache, dizziness, light headedness, blurred vision, headache: 3 (3.8%) Kim 2001 Not stated Olanzapine n=20 Pae 2004 Unclear Quetiapine n=22 Parellada 2004 Prakanratta 2007 UKU Side Effect Scale for psychotropic drugs (48 symptoms in psychiatric, neurological, autonomic and other domains). Investigator reports. Certain postoperative adverse outcomes were prespecified, but no mention of adverse effects monitoring Risperidone n=64 Risperidone n=63 Placebo n= 64 Withdrawals due to AE: 2 (2.5%) [Both patients who stopped due to AE (worsening delirium) were > 80 yrs] None Mild sedation, dry mouth: 2 None EPS, dyskinesia, dystonia: 0 Mild sedation: 3 Withdrawals due to AE: 1 (4%). (due to sedation) None Total AEs: 5 Drowsiness - 2 (3.1%) Nausea - 1 (1.6%) Acute renal failure - 1 Seizure -1 Postoperative adverse outcomes: Renal Failure - 1 (3.2%) Respiratory Failure - 1 (3.2%) Arrhythmia - 1 (9.5%) Cardiovascular instability - 3 (4.8%) Tracheal re-intubation - 0 Postoperative adverse outcomes: Renal Failure - 3 (4.8%) Respiratory Failure - 4 (6.3%) Arrhythmia - 6 (9.5%) Cardiovascular instability 4 (6.3%) Tracheal re-intubation - 4 (6.3%)

9 DELIRIUM APPENDICES (Draft for Consultation) Table D8: Study comparing cholinesterase inhibitors against control in delirium Author Setting Study design Age Male/Female Drug & Dose Mean duration Comparator Liptzin 2005 Prevention or treatment of delirium in patients having joint replacement surgery Randomized double blind placebo controlled /46 Donepezil 5mg once daily 28 days Placebo Table D9: Study comparing cholinesterase inhibitors against control in delirium Methods used for AEs Drug Comparator Drug AE details Comparator AE details Liptzin 2005 Not stated Donepezil n=39 Placebo n=41 No difference in the rate of discontinuation. More than 25% of subjects took less than 28 days of assigned treatment. This was apparently not due to side effects, as rates (of side effects) were equivalent between drug and placebo. Table D10: Study comparing ondansetron against control in delirium Author Study design Setting Age Male Drug & Dose Comparator Mean duration /Female Bayindir 2000 Open label uncontrolled trial Treatment of post cardiotomy delirium 51 23/15 Ondansetron 8 mg iv None Single dose Table D11: Study comparing ondansetron against control in delirium Author Bayindir 2000 Methods used for AEs Not stated. Drug Comparator Drug AE details Comparator AE details Ondansetron n=35 None No constipation, headache, extrapyramidal effects, or rise in liver enzymes were observed in this study. It is safe, effective and without apparent side effects. Page 9 of 14

10 Table D12: Studies reporting on stroke adverse events Reference Gill et al., (BMJ 2005) Study type/ Evidence level Cohort study (retrospective and prospective elements) Canada Number of patients Total N=32710 (17,845 atypical antipsycotic s; 14,865 typical antipsychot ics) Patient characteristics Exposed Unexposed Length of follow-up Inclusion criteria: Older adults with dementia (Ontario Health Insurance plan and ICD-9 codes 290, 331 and 797); 2 cohorts: those who were new users of any of 3 atypical antipsychotics (risperidone, olanzapine and quetiapine) and those who were new users of either high potency typical antipsychotics or low potency typical antipsychotics. Exclusion criteria: Patients receiving non-oral antipsychotics or those with other psychotic disorders that may affect their pattern of drug use. Excluded patients taking antipsychotic drug clozapine as this was rarely used at the time of the study in Ontario. Not included cohort of nonantipsychotic users as preliminary data show several important baseline differences between patients receiving antipsychotics and those not receiving antipsychotics. Not include cohorts of patients taking other psychotropics for BPSD such as trazadone or valproate, as these are used for other indications. Baseline Atypical antipsyc hotics (N=1784 5) antispyc hotics (N=1486 5) Mean age 82.5 (7.3) 82.7 (7.4) (years) Men/women 36%/64% 39%/61% Risperidone Olanzapine Quetiapine 75.7% 19.4% 4.9% vs atypical antipsychotics Mean duration of follow-up: (264) days for atypical group; (335.4) for typical group. Patients were observed until they were admitted to hospital with ischaemic stroke, stopped taking their antipsychot ic, died or the study ended. Outcome measures Primary outcome: admission to hospital with a most responsible diagnosis of ischaemic stroke Source of funding Grant from Departm ent of Veterans Affairs, USA.

11 DELIRIUM APPENDICES (Draft for Consultation) Reference Study type/ Evidence level Effect size Outcome measure Number of patients Patient characteristics Exposed Unexposed Length of follow-up Atypical antipsychotics (N=17845) antispychotics (N=14865) Total population (main analysis) Number (%) of new admissions for ischaemic stroke 284 (1.6) 227 (1.5) Number of events per 1000 person years Adjusted HR* 1.01 (95%CI 0.81 to 1.26) 1.0 (reference) Subgroup analyses Outcome measures Source of funding 1. History of stroke Number (%) of new admissions for ischaemic stroke 103 (7.7) 75 (6.3) Number of events per 1000 person years Adjusted HR* 0.8 (0.55 to 1.16) Long-term care resident at baseline Number (%) of new admissions for ischaemic stroke 124 (1.5) 98 (1.3) Number of events per 1000 person years Adjusted HR* 1.15 (0.82 to 1.60) Chronic users Number (%) of new admissions for ischaemic stroke 214 (1.6) 163 (1.6) Number of events per 1000 person years Adjusted HR* 0.89 (0.69 to 1.17) History of AF Number (%) of new admissions for ischaemic stroke 52 (2.6) 34 (2.0) Number of events per 1000 person years Adjusted HR* 1.23 (95%CI 0.70 to 2.02) 1.0 *Multivariate analysis (Cox proportional hazards models) adjusted for confounders: age; gender; low income; residence in long-term care; frequency of medical contact; medical conditions such as prior stroke in past 5 years, history of AF, hypertension, diabetes, acute MI in past 3 months, congestive heart failure; number of distinct drugs; chronic use of antipsychotics ( 2 consecutive prescriptions); overall burden from comorbid disease; concomitant use of drugs that may influence the risk of stroke or recognition; year of entry to the study. Page 11 of 14

12 Reference Douglas et al (BMJ 2008) Study type/ Evidence level Self-controlled case-series* UK (patients from GPRD General Practice Research Database) *Selfcontrolled case-series method (intraperson comparisons in a population of individuals who have both the outcome and exposure of interest. Rate ratios compare the rate of events during exposed periods of time with the rate during all other observed time periods. This removes the potential effect of confounding characteristics that vary between individuals and risk factors for vascular disease. Number of patients Total N=6790 (n=905 atypical antipsychot ic, n=6334 typical antipsychot ic drug) Patients with dementia: Total n=1423 (n=1208 typical antipsych otic, n=85 atypical antipsych otic drug) Patient characteristics Exposed Unexposed Length of follow-up Inclusion criteria: all patients with a first ever incident diagnosis of stroke at least 12 months after initial registration with the database. Had to have the incident of stroke before Dec 2002 and also to have been prescribed at least 1 antipsychotic medicine before this date (this was done to eliminate possible changes in prescribing pattern as concerns of AEs in elderly arose around this time) Median age to first exposure to any antipsychotic drug was 80. Most common atypical antipsychotic drug was risperidone (n=729) Risperidone Olanzapine Quetiapine Amisulpride 81% 18% 4% 4% and atypical antipsychotics versus no treatment Median duration of antipsychotic exposure 0.37 (IQR 0.10 to 1.23) years Outcome measures Association between exposure to antipsychoti cs and Stroke Source of funding MRC of Canada

13 DELIRIUM APPENDICES (Draft for Consultation) Reference Study type/ Evidence level Number of patients Patient characteristics Exposed Unexposed Length of follow-up Outcome measures Source of funding Effect size Outcome measure (rate ratio association between exposure Any antipsychotic (N=1423) antipsychotics (N=1208) Atypical antipsychotics (N=85) and stroke) All patients Exposed vs unexposed periods 1.73 (1.60 to 1.87) 1.69 (1.55 to 1.84) 2.32 (1.73 to 3.10) Patients with recorded dementia (n=1423) Exposed vs unexposed periods 3.50 (2.97 to 4.12) 3.26 (2.73 to 3.89) 5.86 (3.01 to 11.38) Days after treatment (3.34 to 4.87) 3.74 (3.05 to 4.59) 5.70 (2.50 to 12.98) (2.33 to 3.96) 2.92 (2.20 to 3.88) 4.41 (1.40 to 13.89) (1.97 to 3.73) 2.40 (1.69 to 3.41) 3.50 (0.76 to 16.25) (1.45 to 3.15) 2.16 (1.44 to 3.23) 2.21 (0.28 to 17.34) (0.95 to 2.44) 1.49 (0.90 to 2.44) 2.40 (0.30 to 18.88) Page 13 of 14

14 Reference Herrmann et al, (Am J Psychiatry 2004) Study type/ Evidence level Cohort study (retrospective) Canada Number of patients Total N=11400 (1015 typical antipsycotic s; 6964 risperidone; 3421 olanzapine) Patient characteristics Exposed Unexposed Length of follow-up Inclusion criteria: individuals 66 years old who were given at least 2 successive prescriptions and received enough drug for 30 days of observation. Duration of exposure was the period of continuous, exclusive use of any of the study drugs starting from the index date. Hospital admissions for stroke were identified using ICD codes (430, 431, 434, 435 and 436). Baseline antipsyc hotics (N=1015) Risperid one (N=6964) Olanzapi ne (N=3421) Mean age 81.1 (7.8) 82.9 (7.1) 81.2 (7.5) (years) Men/women 34%/66% 31%/69% 31%/69% vs atypical antipsychotics (reference) 13,318 person years of follow-up Follow-up ended with hospital admission for stroke, exposure to a medication from another study group, discontinu ation of the drug, death or end of the observatio n period. Outcome measures Risk of stroke Source of funding None mentione d Effect Size Risk ratio for stroke: 1.1 (0.5 to 2.3) with olanzapine use 1.4 (0.7 to 2.8) with risperidone use Relative to olanzapine, users of risperidone were not at significantly increased risk of stroke-related hospital admission: adjusted risk ratio 1.3 (0.8 to 2.2) Multivariate analysis (Cox proportional hazards model) adjusted for hospitalisations, procedures, drug utilisation hypothesised to be associated with the risk of stroke as well as basic demographic characteristics. The number of prescription drugs dispensed in the year before the index date was included as a measure of overall comorbidity.